Health inspection·April 27, 2023

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to implement their abuse policy and procedure in regards to reporting allegations immediately and conducting an investigation. This affected one out of three residents reviewed for abuse, Resident #69. The facility census was 115. Residents Affected - Few Findings include: Record review revealed Resident #69 was admitted on [DATE] and re-admitted on [DATE] with diagnoses including surgical amputation of the right leg below the knee and left leg above the knee, necrotizing fasciitis, obesity, heart arrhythmias, sleep apnea, high blood pressure with heart failure, respiratory failure, peripheral vascular disease and depression. Review of Resident #69's Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #69 was alert and oriented with intact cognition. The MDS assessment indicated Resident #69 needed extensive assistance with bed mobility, dressing, toilet use and personal hygiene. Review of Resident #69's plan of care initiated on 03/12/21 indicated Resident #69 required assistance with activity of daily living needs related to impaired self care. Interventions on the plan of care included for staff to assist Resident #69 with completion of activity of living needs on a daily basis and ensure needs were met daily and monitor and report changes in range of motion ability. Review of Resident #69's physical therapy note dated 04/18/23 indicated skilled therapy interventions focused on bed mobility with the use of a trapeze bar. The physical therapy note indicated Resident #69 had limited left upper extremity grasp with complaints of pain with the finger digits number four and five. Resident #69 complained of pain with extension of the left finger digits number four and five. The note indicated nursing staff were informed of Resident #69's complaint of left finger pain and requested an x-ray be obtained to rule out a possible fracture. An interview with Resident #69 on 04/26/23 at 10:07 A.M. indicated approximately two months ago (February 2023) an unnamed state tested nursing assistant (STNA) employed by a staffing agency had beat him up including hitting him and twisting his fingers on his left hand. Resident #69 indicated the agency STNA was angry with him and hurt his three fingers on his left hand. Resident #69 stated he was unable to remember all the details of the incident but had informed several staff members (unnamed) of the incident. Resident #69 indicated the facility did not send him to the hospital and he did not have full use of his three fingers on his left hand. During the interview, Resident #69 held up his left hand and demonstrated his inability to fully extend his pinky finger, middle finger and ring finger on his left hand. An interview with Registered Nurse (RN) #120 on 04/26/23 at 2:15 P.M. revealed she had heard a rumor that Resident #69 had informed staff (unnamed) an agency STNA (unnamed) had beat him up and the staff had reported the allegation to the administrative staff (unnamed) and the agency STNA was no (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 7 Event ID: 365290 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365290 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kirtland Woods of Journey 9685 Chillicothe Rd Kirtland, OH 44094 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)